Understanding Dermatologic Concerns Among Persons Experiencing Homelessness: A Scoping Review and Discussion for Improved Delivery of Care

Abstract

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Characterization of dermatological diagnoses among hospitalized patients experiencing homelessness

“…Consistent with outpatient studies, ectoparasitic disease and bacterial skin infections were prevalent among PEH, which may be explained in part by difficulty maintaining adequate hygiene and presence of comorbid psychiatric disorder. 1,2,4 PEH also had increased rates of venous stasis or lymphoedema, likely due to living conditions requiring them to remain on their feet for extended periods of time without opportunities to elevate their legs. 1,9 Our findings suggest that dermatology providers caring for hospitalized PEH should have an increased index of suspicion for these potentially subtle diagnoses.…”

“…1,2,4 PEH also had increased rates of venous stasis or lymphoedema, likely due to living conditions requiring them to remain on their feet for extended periods of time without opportunities to elevate their legs. 1,9 Our findings suggest that dermatology providers caring for hospitalized PEH should have an increased index of suspicion for these potentially subtle diagnoses. Furthermore, these findings emphasize the importance of partnering with community stakeholders to develop public health interventions and increase access to community-based care in order to address these preventable and treatable conditions among PEH.…”

“…Growing housing insecurity, caused in part by the economic impact of the COVID‐19 pandemic, has increased the urgency of addressing the health of people experiencing homelessness (PEH). Previous studies have found that PEH face significant amounts of skin disease and a unique range of dermatological diagnoses in the outpatient setting 1–5 . However, despite PEH having increased hospital utilization, 6 no studies have explored the types of skin disease seen among hospitalized patients experiencing homelessness and whether their distribution of skin diseases differs from that of hospitalized patients with stable housing.…”

Tinea pedis epidemiology and importance from the lens of homelessness and low-resource settings.

“…Examples of oral treatment regimens include uconazole 150 mg per week or griseofulvin 500 mg per week. Terbina ne should generally be avoided in patients with pre-existing liver disease due to the potential for hepatotoxicity [14,15].…”

Association Between Homelessness and Group A Streptococcus Skin and Soft Tissue Infections Among Hospitalized Dermatology Consult Patients

“…Skin and soft tissue infections (SSTIs) are common among persons experiencing homelessness (PEH) . While studies have investigated higher rates of methicillin-resistant Staphylococcus aureus (MRSA) SSTIs among PEH, group A Streptococcus (GAS) also causes SSTIs and requires different first-line antibiotic coverage .…”